HIV in the UK 2016 report UK HIV continuum of care: progress against UNAIDS target
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HIV in the UK 2016 report
UK HIV continuum of care: progress against UNAIDS target
HIV in the UK: 2016 report
2
About Public Health England
Public Health England exists to protect and improve the nation’s health and wellbeing,
and reduce health inequalities. We do this through world-class science, knowledge
and intelligence, advocacy, partnerships and the delivery of specialist public health
services. We are an executive agency of the Department of Health, and are a distinct
delivery organisation with operational autonomy to advise and support government,
local authorities and the NHS in a professionally independent manner.
Public Health England
Wellington House
133-155 Waterloo Road
London SE1 8UG
Tel: 020 7654 8000
www.gov.uk/phe
Twitter: @PHE_uk
Facebook: www.facebook.com/PublicHealthEngland
Suggested citation: Kirwan PD, Chau C, Brown AE, Gill ON, Delpech VC and
contributors. HIV in the UK - 2016 report. December 2016. Public Health England,
London.
Contributors: Adamma Aghaizu, Alex Bhattacharya, Francesco Brizzi, Glenn Codere,
Stefano Conti, Nicholas Cooper, Sara Croxford, Daniela De Angelis, Sarika Desai,
Chris Farey, Amrita Ghataure, Matthew Hibbert, Ford Hickson, Meaghan Kall, Carole
Kelly, Jameel Khawam, Maeve Lalor, Mark McCall, Janice Morgan, Gary Murphy,
Sandra Okala, Anne Presanis, Rajani Raghu, Andrew Skingsley, Lucy Thomas, Claire
Thorne, Jennifer Tosswill, Anna Tostevin, Lesley Wallace, Joanne Winter, Zheng Yin
Thank you to all who provided personal quotes, and to Positively UK for co-ordinating
this activity.
For queries relating to this document, please contact: [email protected]
© Crown copyright 2016
You may re-use this information (excluding logos) free of charge in any format or
medium, under the terms of the Open Government Licence v3.0. To view this licence,
visit OGL or email [email protected]. Where we have identified any third
party copyright information you will need to obtain permission from the copyright
holders concerned.
Published December 2016
PHE publications gateway number: 2016463
HIV in the UK: 2016 report
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Contents
About Public Health England 2
Introduction 4
Key findings and prevention implications 5
Continuum of HIV care 7
Estimated number of people living with HIV 8
Estimates of HIV incidence 11
Persons diagnosed with HIV in 2015 13
Late HIV diagnoses, AIDS and deaths 21
HIV and tuberculosis 24
Transmitted HIV drug resistance 24
People seen for HIV care 26
Experiences of people living with HIV 33
References 35
Appendices 37
HIV in the UK: 2016 report
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Introduction
It is 20 years since the introduction of life-saving, free and effective antiretroviral therapy (ART)
in the UK. Treatment has transformed HIV from a fatal infection into a chronic, manageable
condition and people living with HIV in the UK can now expect to live into old age if diagnosed
promptly. For many people, treatment means one daily tablet with no or few side effects. More
recently, it has been demonstrated that the advantages of ART extend beyond personal clinical
benefit. It is now widely understood that effective HIV treatment results in an ‘undetectable’
viral load which is protective from passing on the virus to others [1, 2].
While testing and treatment for HIV in the UK is free and available to all, over 13,000 people
living with HIV remain undiagnosed and rates of late diagnosis remain high. Late HIV diagnosis
is associated with poorer health outcomes, including premature death [3, 4]. Furthermore,
since the vast majority of people diagnosed with HIV are effectively treated, most new HIV
infections are passed on from persons unaware of their infection [5]. Condoms remain an
important way to prevent HIV and other sexually transmitted infections (STIs) (and unintended
pregnancy) and continue to be recommended, with new and casual partners in particular.
Symptoms due to HIV and AIDS may not appear for many years, and people who are unaware
of their infection may not feel themselves to be at risk. However, anyone can acquire HIV
regardless of age, gender, ethnicity, sexuality or religion and it is essential to challenge
assumptions about who is at risk of HIV. As well as increasing awareness of HIV, efforts to
reduce stigma and other socio-cultural barriers that prevent people from testing and seeking
long-term care must be strengthened.
The good news is that it has never been easier to have an HIV test. Tests are free and
anonymous and available at specialised sexual health services nationwide. In most cases the
test involves a fingerprick and results are ready within minutes. General practitioners (GP’s)
and many other healthcare and community settings also offer HIV tests. Alternatively, a blood
sample can be taken at home and sent to a local laboratory (self-sampling – kits available
online: www.freetesting.hiv) or the test can be performed at home (self-testing).
This report provides the latest data and estimates on the HIV epidemic in the UK and
describes the quality of HIV care delivered through specialised services. For the first time,
survey data that shows what it is like living with HIV is included, as well as personal quotes to
contextualise the experiences of those living with HIV in the UK today.
This report complements an earlier statistical report on the HIV epidemic in the UK, as well as
specific reports on HIV testing and on infections, including HIV, in people who inject drugs [6,
7]. Further information can be found on the Public Health England (PHE) web pages:
www.gov.uk/government/collections/hiv-surveillance-data-and-management
HIV in the UK: 2016 report
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Key findings and prevention implications
The number of people unaware of their HIV infection remains high
In 2015, an estimated 101,200 people (95% credible interval (CrI) 97,500-105,700) were living
with HIV in the UK, of those, 13,500 (95% CrI 10,200-17,800), or 13% (95% CrI 10-17%) were
unaware of their infection and at risk of passing on the virus to others. The majority, 69%
(69,500; 95% CrI 66,300-73,700), were men and 31% (31,600; 95% CrI 30,600-32,800) were
women1. The HIV prevalence in the UK is estimated to be 1.6 per 1,000 population, or 0.16%.
HIV incidence among gay, bisexual and other men who have sex with men remains high
HIV incidence (the number of new infections) among gay, bisexual and other men who have
sex with men, hereafter referred to as gay/bisexual men2, remains consistently high; in England
an estimated 2,800 (95% CrI 1,700-4,400) gay/bisexual men acquired HIV in 2015 with the vast
majority acquiring the virus within the UK. Overall in 2015, 47,000 (95% CrI 44,200-50,900)
gay/bisexual men were estimated to be living with HIV, of whom 5,800 (95% CrI 3,200-9,600),
or 12% (95% CrI 7-19%) remained undiagnosed.
New diagnosis rates remain high, driven by ongoing transmission and sustained testing
In 2015, 6,095 people were diagnosed with HIV: this represents a new diagnosis rate of 11.4
per 100,000 people. This rate is higher than most other countries in western Europe, the
average being 6.3 per 100,000 people in 2015 [9]. The number of people diagnosed each year
in the UK has remained around 6,000 for the past five years, reflecting both testing efforts and
ongoing transmission of the virus.
The epidemic is diverse
People living with diagnosed HIV in the UK represent a diverse group and assumptions about
the characteristics of those living with HIV need to be challenged. Over half (52%;
3,180/6,0953) of all people diagnosed in 2015 were born in the UK, compared with 38%
(2,820/7,439) of people diagnosed in 2006. This is largely due to fewer diagnoses among
heterosexual men and women born abroad, particularly in sub-Saharan Africa; there were
1,110 diagnoses among black African heterosexuals in 2015, compared with 3,170 in 2006. In
1 Figures presented in text are rounded and may not sum to total, unrounded figures are included in appendices.
2 Gay/bisexual men were previously referred to as men who have sex with men (MSM). The large majority of men who have
sex with men who are diagnosed with HIV identify as gay or bisexual [7]. 3 Figures adjusted for missing country of birth information, adjusted and rounded figures are presented throughout.
HIV in the UK: 2016 report
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contrast, the number of gay/bisexual men born abroad has risen; in 2015, two in five
gay/bisexual men diagnosed with HIV were born abroad (compared with two in seven in 2006).
Timely diagnosis of HIV remains a major challenge
Fewer people are diagnosed with an AIDS-defining illness or at a late stage of infection (with a
CD4 cell count less than 350 cells/mm3), but the numbers diagnosed late remain high. In 2015,
among those with CD4 data available, 39% (1,920/4,969) of adults were diagnosed late, a
decline from 56% (3,349/5,974) in 2006. Of concern, people diagnosed late continue to have a
ten-fold increased risk of death in the first year of diagnosis compared with those diagnosed
early. This underscores the need to strengthen the application of testing policies [7].
HIV care is comprehensive and of a high standard for all
In 2015, 88,769 people received HIV care in the UK, up 73% from a decade ago (51,449 in
2006). This reflects the longer life expectancy conferred by effective ART, as well as consistent
numbers of people newly diagnosed. Nearly all (97%) of the 6,095 people diagnosed with HIV
in 2015 were linked to specialist HIV care within three months of diagnosis, similar to previous
years. Furthermore, the vast majority (94%) of people accessing HIV care in 2015 were
receiving ART and as a result have undetectable virus in their blood and body fluids and are
very unlikely to pass on their infection to others.
Early diagnosis of HIV infection means better treatment outcomes and reduced risk of
passing on the virus to others
In 2015, almost 7,000 people started ART for the first time. This compares with an average of
5,500 each year between 2010 and 2014. This rise reflects revised guidelines from the British
HIV Association (BHIVA) and World Health Organisation (WHO) [10, 11] which recommend
that patients start ART at diagnosis regardless of CD4 count both for clinical benefits and
preventing onward transmission. In 2015, two-thirds (66%) of people who started treatment had
a CD4 cell count above 350 cells/mm3 and 41% above 500 cells/mm3. This compares with 22%
and 10% respectively, a decade ago.
How to get an HIV test:
go to an open-access STI clinic (some clinics offer ‘fast-track’ HIV testing) or a
community testing site (www.aidsmap.com/hiv-test-finder)
ask your GP for an HIV test
request a self-sampling kit online (www.freetesting.hiv) or obtain a self-testing kit
Gay, bisexual and other men who have sex with men are advised to test for HIV and other
STIs at least annually and every three months if having sex with new or casual partners.
Black African men and women are advised to have an HIV test and a regular HIV and STI screen if having condomless sex with new or casual partners.
HIV in the UK: 2016 report
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Continuum of HIV care
“When I was first diagnosed in the mid-90s, life was very different. Treatment was awful
with around 20 tablets a day at high strengths. Time has changed and so have
treatments and there is really no reason that you should not live a normal life.”
Gay man, aged 44, diagnosed in 1996
The continuum of HIV care illustrates key measures of HIV care and provides an opportunity to
assess progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS)
90:90:90 targets [12]. This target aims for 90% of people living with HIV to be diagnosed, 90%
of those diagnosed to be receiving HIV treatment and 90% of those receiving treatment to have
a suppressed viral load, by 2020. Overall, this equates to 73% of all people living with HIV
having a suppressed viral load.
In the UK in 2015, 87% (Crl 83-90%) of the 101,200 (95% CrI 97,500-105,700) estimated
number of people living with HIV were diagnosed. Of those diagnosed, 96% were receiving HIV
treatment and of those receiving treatment, 94% had a suppressed viral load (Figure 1). While
the UK is currently falling short of the first UNAIDS target for 90% of people living with HIV to
be diagnosed, the second two metrics have been met and 78% of people living with HIV in the
UK are estimated to have a suppressed viral load, surpassing the overall aim of the UNAIDS
target (73%).
Despite advancements made towards the 90:90:90 treatment target, further efforts are required
to curtail HIV transmission in the UK. Areas of concern include continuing high levels of
transmission and high rates of late HIV diagnosis.
Figure 1: Continuum of HIV care: United Kingdom, 2015
100%
87% 83%
78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
People living with HIV People diagnosed withHIV
On treatment Virally suppressed
87% 96% 94%
HIV in the UK: 2016 report
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Estimated number of people living with HIV
A number of statistical models have been developed to estimate the total number of people
living with HIV in the UK.
A Bayesian multi-parameter evidence synthesis (MPES) model, revised each year to take into
account changes in data sources, was used to estimate the number of people living with
diagnosed and undiagnosed HIV in the UK. In 2016, estimates for heterosexuals were updated
using different and additional data sources. To account for the discontinuation of the Unlinked
Anonymous Dried Blood Spot (UA DBS) survey in pregnant women, estimates for pregnant
women were based upon a combination of data from the National Survey of HIV in Pregnancy
and Childhood and the number of live births occurring each year. As these data sets are much
larger than the UA DBS survey, estimates are more precise. Additional data from the African
Health and Sex Survey [14] were included to strengthen prevalence estimates among
heterosexual men and women.
Based on this data it was estimated that 101,200 (95% CrI4 97,500-105,700) people were living
with HIV in the UK in 2015, of whom 69% (69,500; 95% CrI 66,300-73,700) were men and 31%
(31,600; 95% CrI 30,600-32,800) were women5 (Figure 2). Two in five people (40,300; 95% CrI
38,500-43,600) were living in London.
Using these estimates, the overall prevalence of HIV in the UK in 2015 was 1.6 per 1,000 (95%
CrI 1.5-1.6) among people of all ages and 2.1 per 1,000 (95% CrI 2.0-2.2) among people aged
15-74 years. HIV prevalence was higher among men, estimated at 2.3 per 1,000 (95% CrI 2.2-
2.5) compared with women, estimated at 0.98 per 1,000 (95% CrI 0.95-1.02).
A total of 47,000 (95% CrI 44,200-50,900) gay/bisexual men were estimated to be living with
HIV in 2015 (Appendix 1). Using the estimate that 3.3% of men in the UK are men who have
had sex with other men in the past five years (880,000 out of all men in 2015) [13, 15], the
prevalence of HIV in this population was one in 17, or 58.7 (95% CrI 51.2-68.0) per 1,000. HIV
prevalence among gay/bisexual men was higher in London with one in seven, or 135 (95% CrI
101-184) per 1,000, estimated to be living with HIV, compared with one in 25, or 39.1 (95% CrI
33.4-46.5) per 1,000, in the rest of England and Wales.
In 2015, 19,600 (95% CrI 18,600-21,500) heterosexual men and 29,900 (95% CrI 28,900-
31,000) heterosexual women were estimated to be living with HIV, of whom 9,300 (95% CrI
8,900-9,800) were black African men and 19,300 (95% CrI 18,700-20,000) were black African
4 95% credible intervals describe the statistical uncertainty surrounding estimates from a Bayesian analysis, which correctly and
formally propagates the uncertainty inherent in the data through to the final estimates. 5 Figures presented in text are rounded and may not sum to total, unrounded figures are included in appendices.
HIV in the UK: 2016 report
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women (Appendix 1). The estimated prevalence of HIV among all heterosexuals was low (1.0
(95% CrI 1.0-1.1) per 1,000), but greater among black African adults; 22.2 (95% CrI 21.3-23.6)
per 1,000 among black African heterosexual men and 42.6 (95% CrI 41.0-44.3) per 1,000
among black African heterosexual women.
Figure 2: Estimated number of people living with HIV (both diagnosed and undiagnosed) using the MPES model, all ages: UK, 2015
Other methods can also be used to estimate the number of people living with HIV in the UK. A
recent study, based on a HIV synthesis progression model [16], estimated that in 2013,
106,400 (90% plausibility range6 88,700-124,600) people were living with HIV in the UK, the
MPES estimates lie within this plausible range.
Number of people living with undiagnosed HIV
An estimated 13,500 (95% CrI 10,200-17,800) or 13% (95% CrI 10-17%) of people living with
HIV were living with an undiagnosed infection in 2015 and at risk of passing on their infection if
having unprotected sex.
6 Plausibility ranges are an approximate assessment of uncertainty associated with estimates.
41,200
8,300
17,500
8,100 8,400
2,200
5,800
1,000 1,900 2,100 2,100
300 0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
Men who havesex with men
Black Africanmen
Black Africanwomen
Non black-African men
Non black-Africanwomen
People whoinject drugs
Heterosexual
Pe
op
le liv
ing
wit
h H
IV
Diagnosed Undiagnosed
Total living with HIV = 101,200 (97,500 − 105,700) Total diagnosed = 87,700 (86,300 − 89,300) Total undiagnosed = 13,500 (10,200 − 17,800)
HIV in the UK: 2016 report
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In 2015, 12% (95% CrI 7-19%) of gay/bisexual men, 16% (95% CrI 12-23%) of heterosexual
men and 13% (95% CrI 11-16%) of heterosexual women living with HIV were estimated to be
unaware of their infection7. The proportion undiagnosed was higher amongst populations
considered to be at lower risk of HIV; among non-black African heterosexual men and women,
21% (95% CrI 14-32%) and 20% (95% CrI 16-25%) were unaware of their infection,
respectively. The proportion of black African heterosexual men and women unaware of their
infection was 11% (95% CrI 8-16%) and 10% (95% CrI 16-25%), respectively.
Over 95% of all people living with HIV in the UK most likely acquired their infection through
sexual contact, around half of whom were heterosexuals and half were gay/bisexual men.
Although less common as a route of HIV exposure, HIV transmission continues among people
who inject drugs (PWID) and the emergence of injecting drug use as part of/during sex
(referred to as slamming/slamsex) among gay/bisexual men is of concern [8].
In 2015, an estimated 2,500 (95% CrI 2,200-2,800) people who inject drugs (PWID) were living
with HIV in the UK, of whom 315 (95% CrI 156-568) or 13% (95% CrI 7-21%) were estimated to
be living with an undiagnosed infection. HIV prevalence among PWID aged 15-74 was
estimated to be 3.8 (95% CrI 2.6-5.3) per 1,000.
Among people living with HIV in London, 11% (95% CrI 7-18%) were estimated to be unaware
of their HIV infection, this compares with 13% (95% CrI 10-17%) in those living in England and
Wales, outside of London7. An estimated one third (4,400; 95% CrI 2,800-7,800) of all people
living with undiagnosed HIV in the UK were living in London (Appendix 2).
A similar proportion of gay/bisexual men within London (10%; 95% CrI 4-23%) were unaware of
their infection as those outside of London (11%; 4-19%) and very similar proportions were
estimated for black African heterosexuals (Appendix 2). Geographical differences in
undiagnosed HIV were observed among non-black African men and women, with the
proportion of undiagnosed infection within London (14% (95% CrI 7-28%) and 16% (95% CrI
10-24%) respectively) being lower than the proportion outside of London (23% (95% CrI 14-
37%) and 21% (95% CrI 16-29%) respectively).
In comparison with estimates above, made using the MPES model, a recent study using a HIV
synthesis progression model estimated that 24,600 (90% plausibility range 15,000-36,200)
people with HIV were living with an undiagnosed infection in 2013 [16]. Again, this range
overlaps the credible intervals of the MPES model estimates. The model estimated that 19%
(90% plausibility range 9-28%) of gay/bisexual men were unaware of their infection in 2013 and
26% (90% plausibility range 22-26%) and 20% (90% plausibility range 17-34%) of black African
men and women heterosexuals, respectively.
7 Numbers of undiagnosed are included in appendices.
HIV in the UK: 2016 report
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Estimates of HIV incidence
“Being diagnosed recently came as a shock, if not a total surprise. As a gay man in
middle age, I’ve grown up with the AIDS epidemic and like most gay men I’ve been under
its cloud. I’ve reached out to HIV support organisations to better manage my own self-
care and through this have met others who are living well with the virus. I’m now able to
live life to the full, much as before.”
White gay man, aged 47
A CD4 back-calculation model was used to estimate HIV incidence among gay/bisexual men
living in England and also provides an estimate on undiagnosed prevalence in this group [17].
This method is not currently used for other populations, due to the complexity of incorporating
the effects of migration.
In 2015, a total of 2,800 gay/bisexual men (95% credible interval 1,700-4,400) were estimated
to have acquired a new HIV infection in England (Figure 3). This is in line with the previous five
years where an estimated 2,800 men on average acquired HIV each year between 2010 and
2014.
Figure 3: Back-calculation estimates of HIV incidence and number of prevalent undiagnosed HIV infections (including 95% credible interval) by CD4 strata, among gay/bisexual men aged 15 years and over: England, 2006-2015
0
1,000
2,000
3,000
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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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fec
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CD4 < 200
200 ≤ CD4 < 350
350 ≤ CD4 < 500
CD4 ≥ 500
Estimated incidence
95% credible interval of estimated incidence
HIV in the UK: 2016 report
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Based on results of the CD4 back-calculation model, a total of 7,800 gay/bisexual men (95%
CrI 6,000-10,200) were estimated to be living with an undiagnosed HIV infection in England in
2015; a number which has remained stable over the decade. The estimated distribution of CD4
strata among those living with an undiagnosed infection has varied little over the past ten years
with around half of those living with an undiagnosed infection having a CD4 count above 500
cells/mm3 (Figure 3). It is likely that these men acquired their infection within the past one to
three years [18].
The estimate for the number of gay/bisexual men living with an undiagnosed HIV infection
through the CD4 back-calculation lies in the upper bound of the estimate produced by the
MPES model 4,700 (95% CrI 2,300-8,400) in England and Wales in 2015. As these
methodologies use different data sources, it is likely that the true number of gay/bisexual men
living with undiagnosed HIV lies between the two.
Estimates of HIV incidence were also made in a recent study using a HIV synthesis
progression model [16], where 2,500 (90% plausibility range 900-5,800) new HIV infections
were estimated to have been acquired annually among gay/bisexual men between 2010 and
2013, similar to estimates produced through the CD4 back-calculation model. The synthesis
progression model is able to produce annual estimates for the entire population and estimated
4,700 (90% plausibility range 2,000-9,800) new HIV infections annually with 1,200 (90%
plausibility range 800-2,300) among black African heterosexuals between 2010-2013.
HIV in the UK: 2016 report
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Persons diagnosed with HIV in 2015
“Just a few words from someone who has been living with HIV for nearly 20 years: it’s not that bad and there are times when you forget you have HIV. Eventually, even when you remember you’re positive, it’s no longer an issue.” White woman, aged 44
In 2015, 6,095 people were newly diagnosed with HIV, (4,551 men and 1,537 women8).
Although a slight decrease on the 6,172 diagnoses recorded in 2014, the annual number of
new HIV diagnoses remains high and represents an annual HIV diagnosis rate of 11.3 per
100,000 people aged 15 years and over (17.3 per 100,000 men and 5.5 per 100,000 women).
The number of new HIV diagnoses has declined from 7,439 in 2006, largely due to a decrease
in diagnoses reported among heterosexuals born abroad. In 2015, the UK had one of the
highest rates of new HIV diagnosis in western Europe, where the average rate is 6.3 per
100,000 people [9]. High rates of new HIV diagnosis in the UK are due to both ongoing
transmission and high testing rates in STI clinics.
London accounted for almost half (43%; 2,603/6,095) of new HIV diagnoses in the UK in 2015,
with the Midlands and East of England PHE region contributing the largest number of new
diagnoses outside of London (19%; 1,181/6,095).
Most people (71%; 4,324/6,095) diagnosed were aged between 25 and 49 years. However, the
proportion diagnosed at age 50 years and over has increased from 9% (667/7,439) in 2006 to
17% (1,018/6,095) in 2015.
In 2015, for the first time since the 1990s, the proportion of people diagnosed with HIV who
were born in the UK (52%; 3,160/6,0959) exceeded the proportion born abroad (48%;
2,900/6,095) (Figure 4a). The shift is largely due to a steep decline in the number of new
diagnoses among heterosexuals, (particularly women) born abroad (Figure 4b).
8 Gender was not reported for seven individuals.
9 Figures adjusted for missing country of birth information, adjusted and rounded data are presented throughout.
HIV in the UK: 2016 report
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Figure 4: New HIV diagnoses by place of birth and gender: UK, 2006-2015 a)
b)
Gay/bisexual men
“After the initial shock HIV became very much a background aspect of my life. Both
myself and my partner continue to live our lives as if we were unaffected by HIV.”
White gay man, diagnosed 2004
The number of new HIV diagnoses reported among gay/bisexual men steadily increased from
2,670 in 2006 to 3,360 in 2014 and has remained high in 2015 at 3,320. The sustained high
level of new diagnoses among gay/bisexual men is explained by the combination of an
increase in the levels of HIV testing, as well as ongoing high rates of transmission.
London had the highest number of new HIV diagnoses among gay/bisexual men in 2015
(1,373), followed by the PHE regions of the North of England (469), the South of England (404)
and the Midlands and East of England (402). There were 122, 91 and 58 diagnoses among
0
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2,000
3,000
4,000
5,000
6,000
7,000
8,000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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Men Women
Men WomenUK born:
Born abroad:
HIV in the UK: 2016 report
15
gay/bisexual men in Scotland, Wales and Northern Ireland, respectively. Diagnoses made in
London have accounted for much of the rise in the numbers of gay/bisexual men with HIV over
the past decade, with the number of diagnoses remaining constant across other PHE regions
(Figure 5).
Figure 5: Geographical trends of new HIV diagnosis among gay/bisexual men: UK, 2006-2015
The median age at diagnosis for gay/bisexual men was 33 years (inter-quartile range (IQR) 32-
33) in 2015, this compares with 35 (IQR 35-36) in 2006. This change is reflected in the
increasing proportion of men aged under 35 years at the time of diagnosis, from 47%
(1,238/2,627) in 2006 to 56% (1,644/2,923) in 2015 (Figure 6). Despite declining numbers of
diagnoses in the 35-49 age group, a rise was also observed among gay/bisexual men in the
upper age groups; one in nine (329/2,923) gay/bisexual men were aged 50 years or over at
diagnosis in 2015, compared with one in 11 (233/2,627) in 2006.
Figure 6: Distribution of HIV diagnoses among gay/bisexual men by age group at diagnosis: UK, 2006-2015
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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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London WalesMidlands and East of England Northern IrelandNorth of England ScotlandSouth of England
HIV in the UK: 2016 report
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By assigning probable country of infection based upon information on CD4 decline10, the
number of gay/bisexual men estimated to have acquired their infection in the UK has remained
stable at around 2,000 per year for the past decade, with no difference in trend between those
born in the UK and those born abroad (Figure 7a). In contrast, the number of gay/bisexual men
estimated to have acquired their infection abroad has risen from 419 (uncertainty range 201-
59011) in 2006 to 762 (uncertainty range 608-847) in 2015, with the rise driven by increasing
numbers of diagnoses among gay/bisexual men born abroad (Figure 7b).
Figure 7: New HIV diagnoses among gay/bisexual men by region of birth and probable country of acquisition1: UK, 2006-2015
Heterosexual men and women
“The day I was giving a positive HIV diagnosis I thought all my life will be ruled by it, but today I see HIV as a tiny virus I control.” African women, aged 36
In 2015, 1,350 women and 1,010 men who probably acquired HIV through heterosexual
contact were diagnosed. The number of new diagnoses among heterosexuals has declined by
almost half over the past decade, from 4,340 (58%) in 2006 to 2,360 (39%) in 2015,
10
Probable country of infection is assigned based upon information on CD4 decline for those born abroad, as in [18]. Clinician-
reported probable country of infection is used for those born in the UK. 11
Uncertainty ranges are calculated using interquartile range, with an adjustment for those with missing region of birth
information.
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1Figures adjusted for missing exposure category and region of birth.
HIV in the UK: 2016 report
17
predominantly due to fewer reports among African-born men and women, which reflects
changing migration patterns. This decline was particularly steep in England overall (from 4,009
to 1,837) and London (from 1,582 to 679) (Figure 8).
In 2015, the number of diagnoses among heterosexuals was highest in London (679), followed
by the Midlands and East of England (516), North of England (348) and South of England
(294). In Wales, Northern Ireland and Scotland the number of new diagnoses among
heterosexuals was lower, with 35, 35, and 72 respectively.
Figure 8: Geographical trends of new HIV diagnosis among heterosexuals: UK, 2006-2015
The median age at diagnosis in 2015 was 42 among heterosexual men and 39 among
heterosexual women (compared with 33 among gay/bisexual men). More than a quarter (28%)
of heterosexual men were aged 50 years or over at the time of their diagnosis, compared with
18% of heterosexual women. This compares to 13% and 7% in 2006 respectively.
In 2015, black African men and women constituted 47% (1,110/2,360) of new HIV diagnoses
among heterosexuals, after adjusting for missing information (Figure 9). This decrease, from
73% (3,170/4,340) in 2006, is likely due to changing migration patterns. In 2015, one in three
(35%; 820/2,360) heterosexuals diagnosed was of white ethnicity, compared to one in six in
2006 (16%; 690/4,340). However, the overall number of diagnoses in this group has remained
stable over the past decade. Six per cent (140) of diagnoses among heterosexuals were made
among black Caribbean/black other men and women in 2015. Equivalent figures were 5% (120)
and 7% (170) among heterosexuals of Asian and other/mixed ethnicity respectively.
0
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HIV in the UK: 2016 report
18
Figure 9: New HIV diagnoses among heterosexuals by ethnicity: UK, 2006-2015
By assigning probable country of infection based upon information on CD4 decline, as for
gay/bisexual men, the number of heterosexuals estimated to have acquired HIV within the UK
has declined from 1,425 (uncertainty range 898-2,084) in 2006 to 922 (uncertainty range 825-
1,016) in 2015, with the decline observed among those born abroad (Figure 10a). The number
of heterosexuals estimated to have acquired HIV abroad has seen a much steeper decline from
1,893 (uncertainty range 1,234-2,420) in 2006 to 633 (uncertainty range 539-730) in 2015.
Again, this decline has been driven by falling numbers of diagnoses in those born abroad
(Figure 10b). Despite this, these figures highlight the continuing need for effective prevention
strategies among migrant communities within the UK.
Figure 10: New HIV diagnoses among heterosexuals by region of birth and probable country of acquisition1: UK, 2006-2015
0
500
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1,500
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UK born
Born abroad
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b) Acquired abroad
1Figures adjusted for missing exposure category and region of birth.
HIV in the UK: 2016 report
19
People who inject drugs
People who inject drugs (PWID) accounted for 3% (210) of new HIV diagnoses in 2015, a
notable increase on the number diagnosed in recent years (160 in 2014). The increase is
associated with an HIV outbreak among PWID living in Glasgow in 2015, which led to the
diagnosis of over 50 people. Overall, the number of persons newly acquiring HIV through
injecting drug use in the UK remains low. Over half (56%; 117/210) of diagnoses in PWID were
among those born in the UK, 83 were men and 34 were women.
The ‘Shooting Up’ report, published by PHE, on infections among people who inject drugs
includes further details of HIV acquisition and transmission in this group [6].
Mother to child transmission
“I came to the UK in 2004 hoping I could have a better life but all that changed when,
a few months after arriving here, I was diagnosed with HIV. After a few years I entered a
relationship and we decided to have children. My HIV consultant assured me that it was
fine since my viral load was undetectable. I had my twins through C-section which was
planned.”
African woman, aged 41
In 2015, 130 diagnoses were made among those who acquired their infection through mother
to child transmission12 – all except one were born outside of the UK.
Of the 860 children born to mothers living with HIV in the UK during 2015, one child acquired
HIV through mother to child transmission; in this instance the mother presented for antenatal
care late. A further 517 children were reported to have an “indeterminate” HIV status but are
very unlikely to have acquired HIV. This is because almost all were born to women who were
already aware of their HIV status and receiving effective ART. The remaining 342 children were
reported to be uninfected. The risk of mother to child transmission of HIV in the UK is extremely
low (below 0.5% between 2013 and 2015).
Recent infections
People diagnosed promptly are less likely to experience morbidity associated with HIV, are
likely to respond better to treatment and to achieve a suppressed viral load more swiftly [19],
highlighting the importance of prompt diagnosis.
12
This figure is greater than the 65 diagnoses reported among children as it contains individuals diagnosed abroad as children
who have arrived in the UK as adults.
HIV in the UK: 2016 report
20
In 2015, 46% of newly diagnosed individuals were tested for recent infection using the recent
infection testing algorithm (RITA) [20]. Overall, 19% of those tested were likely to have acquired
their infection within the four months preceding their HIV diagnosis13, this compares with 23% in
2014. The proportion diagnosed at a recent stage of infection was higher among gay/bisexual
men (27%) than among heterosexual men (10%) and women (8%) (Appendix 4).
13
Data prior to 2014 used the cut-off of six months to define recent infection.
HIV in the UK: 2016 report
21
Late HIV diagnoses, AIDS and deaths
“I was diagnosed in 1991. Some people with HIV in the UK continue to be diagnosed late,
which often means that they are desperately unwell before they go on treatment – like in
the 90s when I was diagnosed and before we had the very effective treatment we have
now. Testing early means that you can start treatment earlier and not get to the point
where you are sick.”
Heterosexual woman, aged 57
Late HIV diagnoses
Late diagnosis is the most important predictor of morbidity and premature mortality among
people with HIV infection [3, 4]. For surveillance purposes, a late HIV diagnosis is defined as
having a CD4 cell count <350 cells/mm3 within three months of HIV diagnosis. People
diagnosed late are likely to have been living with an undiagnosed HIV infection for at least three
years and may have been at risk of passing on their infection to partners.
In 2015, 39% (1,920/4,969) of adults were diagnosed with HIV infection at a late stage of
infection (CD4 <350 cells/mm3) and 21% (1,030/4,969) were severely immunocompromised at
the time of their diagnosis, with a CD4 count <200 cells/mm3.
The proportion diagnosed late was highest among heterosexual men (54%; 419/769) and
women (48%; 441/922) (Figure 11) and particularly high among those of black African ethnicity
(men (59%; 160/272) and women (51%; 249/485)). The lowest proportion of late diagnosis was
among gay/bisexual men, with 30% (777/2,628) diagnosed late. Overall, 45% (62/139) of
persons who acquired HIV through injecting drug use were diagnosed late.
Rates of late diagnosis varied regionally, with the highest rate seen in the North of England
(47%), followed by the Midlands and East of England (46%), South of England (41%) and
London (32%). In Scotland, Wales and Northern Ireland, 31%, 51% and 29% of people were
diagnosed late, respectively.
The proportion of people diagnosed late has declined from 56% (3,349/5,974) in 2006 to 39%
(1,920/4,969) in 2015 and across all exposure groups. The decline was steepest among
heterosexual women (from 64% to 48%), due in part to the antenatal screening programme, as
well as changing migration patterns.
Rates of late HIV diagnosis is a key indicator in PHE’s Public Health Outcomes Framework
(PHOF), accessible from the following webpage: www.phoutcomes.info.
HIV in the UK: 2016 report
22
Figure 11: Proportion of adults diagnosed with a CD4 cell count <350 cells/mm3 by demographic: UK, 2015
AIDS and deaths among people with HIV
The number of AIDS diagnoses and deaths has steadily declined over the past decade. In
2015, 305 people were diagnosed with an AIDS-defining illness at, or within three months of,
their HIV diagnosis, less than half the number diagnosed with AIDS at diagnosis in 2006 (714).
The most commonly diagnosed AIDS-defining illness was Pneumocystis pneumonia,
accounting for 43% (132/305) of AIDS diagnoses in 2015, followed by oesophageal candidiasis
(11%; 33/305) and Mycobacterium tuberculosis (9%; 27/305).
In 2015, 594 people with HIV infection died and over half of deaths (58%; 347/594) were
among people aged 50 years and over.
All-cause mortality among people living with HIV aged 15-59 years has declined from 10.2 per
1,000 in 2006 to 5.7 per 1,000 in 2015. This compares with a mortality rate of 1.6 per 1,000
aged 15-59 for the general population in 2015 [21]. Mortality rates were higher among men (6.4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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HIV in the UK: 2016 report
23
per 1,000) compared with women (4.3 per 1,000). In the general population, this was 1.9 per
1,000 and 1.2 per 1,000, respectively [21].
In 2015, mortality rates were similar among gay/bisexual men and heterosexuals with
diagnosed HIV, at 4.8 per 1,000 and 4.3 per 1,000, respectively. People diagnosed with HIV
who injected drugs had the highest rate of death, with 25.0 per 1,000.
People diagnosed late are at increased risk of developing an AIDS-defining illness and
continue to have a ten-fold increased risk of death in the year following their diagnosis, as
compared with those diagnosed promptly (31.5 per 1,000 compared to 3.6 per 1,000) (Figure
12). One-year mortality was particularly marked among people aged 50 years and over, where
one in 16 diagnosed late died within a year of diagnosis.
Figure 12: One-year mortality among adults newly diagnosed with HIV by CD4 count at diagnosis: UK, 2014
0
10
20
30
40
50
60
70
Me
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00
)
CD4 <350
CD4 ≥350
HIV in the UK: 2016 report
24
HIV and tuberculosis
In 2014, 205 adults living with HIV were diagnosed with tuberculosis (TB) in England, Wales
and Northern Ireland. This rate is substantially higher than in the general population (12 per
100,00014). TB incidence was highest among people living with HIV who were born in a country
with high prevalence of both infections [22].
People living with HIV are at increased risk of co-infections related to immunodeficiency.
Mycobacterium tuberculosis (MTB) remains one of the most common AIDS-defining illnesses in
the UK and HIV testing should be one of the routine tests offered to TB patients. Indeed, BHIVA
recommends testing for latent TB infection (LTBI) for people living with HIV with a low CD4 cell
count, or if they come from a sub-Saharan country where HIV and TB co-infection is more
common [23].
Transmitted HIV drug resistance
Testing the HIV virus for drug resistance at the time of HIV diagnosis is routinely conducted in
the UK. Between 2011 and 2014, the prevalence of transmitted drug resistance (TDR) (defined
as the presence of one or more mutations of the HIV virus from the WHO 2009 Surveillance list
[24]) remained stable and an average of 7.2% of persons tested had detectable drug
resistance. Transmitted resistance to the different drug classes remained low and stable with
1.8% of people tested having mutations affecting the protease inhibitor (PI) drug class, 3.2%
with mutations affecting the nucleoside reverse transcriptase inhibitor (NRTI) drug class and
3.1% with mutations affecting the nonnucleoside reverse transcriptase inhibitor (NNRTI) drug
class (Figure 13a). Clinically relevant resistance to currently recommended first line drugs also
remains low – below 10% in 2010-2013 [25].
In 2014, the prevalence of TDR among gay/bisexual men was very similar to that of
heterosexual men and women. However, prevalence has declined among gay/bisexual men in
recent years while remaining stable or increasing among heterosexuals (Figure 13b).
14
Denominator includes all people living with HIV (both diagnosed and undiagnosed).
HIV in the UK: 2016 report
25
Figure 13: Transmitted drug resistance among adults newly diagnosed with HIV: UK, 2002-2014
a) By drug class
b) By exposure group
0
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12
14
16
% T
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HIV in the UK: 2016 report
26
People seen for HIV care
“I was diagnosed late with HIV and admitted to hospital. Key to my recovery has been
HIV care coordinated and delivered with empathy and understanding.”
Asian woman, aged 46
HIV care in the UK is of a very high standard and available free of charge across the UK at
specialist HIV services. In 2015, 88,769 people (61,097 men and 27,672 women) living with
diagnosed HIV infection received HIV care in the UK. This is a 4% increase on the number
seen for care in 2014 (85,396) and a 73% increase on the number a decade before (51,449 in
2006).
This rise is due to a combination of ongoing transmission and improvements in therapies which
have increased the lifespan of people living with HIV. In 2015, one in three (34%;
29,960/88,769) people accessing HIV specialist care was aged 50 years and above, this
compares with one in seven in 2006 (14%; 7,320/51,449). The median age of people accessing
care has increased, from 39 in 2006 to 45 in 2015 over the past decade (Figure 14).
Figure 14: People diagnosed with HIV accessing HIV specialist care, by age group: UK, 2006-2015
In 2015, one in seven (14%; 5,780/41,920) gay/bisexual men accessing HIV care was from
black or other minority ethnic groups, this compares with one in eight (12%; 2,620/22,060) in
2006 (Figure 15a). Among heterosexuals, although black African men and women make up the
greatest proportion of those accessing care in 2015 (61%; 25,990/42,710), one in four (25%;
10,700/42,710) heterosexuals were white (Figure 15b), 7% (2,960/42,710) were of black
Caribbean/black other ethnicity and 4% (1,600/42,710) reported an Asian ethnicity.
0
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<15 15-24 25-34 35-49 50-64 65+
HIV in the UK: 2016 report
27
Figure 15: Trends in people diagnosed with HIV accessing HIV specialist care, by ethnicity: UK, 2006-2015
a) Gay/bisexual men
b) Heterosexual men and women
The prevalence of diagnosed HIV varies considerably throughout the UK. Figure 16 shows the
diagnosed prevalence per 1,000 population aged 15-59 years, with the darker two shades
indicating local authorities (LAs) with a rate of two per 1,000 or higher. In 2015, 74 (23%) out of
the 325 LAs in England fell into this category, including all those in London. Eighteen of the 33
LAs in London had a diagnosed HIV prevalence above five per 1,000 population. Outside of
London, Manchester and Brighton and Hove had levels over five per 1,000 largely due to high
numbers of gay/bisexual men living with diagnosed HIV in this areas (Appendix 6).
0
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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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White Black African
Black Caribbean / Black other Asian
Other
0
5,000
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45,000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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HIV in the UK: 2016 report
28
Recently revised English testing guidelines, published in 2016 [26], recommend that expanded
HIV testing is undertaken in LAs with a diagnosed HIV prevalence above two per 1,000
population. See PHE’s 2016 report on HIV testing for further details [7].
Figure 16: Diagnosed HIV prevalence per 1,000 population aged 15-59 years, by local authority of residence: England, 2015
HIV in the UK: 2016 report
29
Linkage to HIV care
“Attending the HIV clinic gives me as much anonymity as is possible and I believe it is
the best place to have specialised care.”
White gay man, aged 40
Prompt linkage to HIV care following an HIV diagnosis is vital in order to ensure that people can
access life-saving treatment and reduce the risk of infection to partners. BHIVA investigation
and monitoring guidelines [27] recommend that all persons diagnosed with HIV are seen for
specialist care and have a baseline CD4 count within two weeks of diagnosis.
In 2015, 75% (3,856/5,149) of people had a baseline CD4 count (conducted as part of initial
assessment and therefore used as a proxy for linkage to care) within two weeks, 86%
(4,426/5,149) within one month and almost all (97%; 4,981/5149) within three months of HIV
diagnosis (Figure 16). Linkage to care was high across almost all demographics and exposure
categories, with the exception of people who acquired HIV through injecting of drugs where
three quarters (76%; 115/151) were linked to care within a month, compared with 86%
(4,311/4,998) among all other exposure groups (Figure 17).
Figure 17: Linkage to care: proportion of adults with a CD4 count within one and three months of diagnosis1: UK, 2015
0%
10%
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60%
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Linked within 1 month Linked within 3 months
1Excludes 946 individuals diagnosed in 2015 with a CD4 count not reported within 12 months of diagnosis.
HIV in the UK: 2016 report
30
Retention in HIV care
The large majority (93%; 79,611/85,396) of adults reported in 2014 were seen again for HIV
care in 2015. Rates were similar for all demographics and exposure categories.
Treatment coverage
The revised 2015 WHO and BHIVA treatment guidelines recommend that all people living with
diagnosed HIV infection should be offered treatment as soon as possible after diagnosis to
prevent onward transmission [10, 11].
In 2015, 96% (83,931/87,81315) of people who attended for HIV care in the UK were receiving
treatment; this was a marked improvement on the 90% (76,726/85,07016) receiving treatment in
2014. This increase is likely to reflect the updated treatment guidelines. Treatment coverage
was high in all geographies and across exposure categories. However, there was variation in
treatment coverage by age, with lower coverage rates among younger people aged 15-24, 88%
(2,019/2,298) compared with 98% (29,172/29,811) among those aged 50 and above (Figure
18).
Almost 7,000 people started ART for the first time in 2015. This compares with an average of
5,500 each year between 2010 and 2014. On average, people are starting treatment at an
earlier stage of infection. Two-thirds (66%) of people who started treatment in 2015 had a CD4
cell count above 350 cells/mm3 and 41% had a CD4 cell count above 500 cells/mm3. This
compares with 22% and 10%, respectively, in 2006.
15
Excludes 956 people who did not have treatment information reported. 16
Excludes 326 people who did not have treatment information reported.
HIV in the UK: 2016 report
31
Figure 18: Treatment coverage: proportion of adults receiving antiretroviral treatment: UK, 2015
Virological suppression
“I’ve been undetectable for almost 15 years. The latest research has shown the chances of passing on HIV is [almost] zero. That’s excellent news and has lifted the psychological burden and fear I carried for so long about transmitting HIV to someone else.” Black Caribbean man, aged 47
Virological suppression is defined as having a viral load less than 200 copies/mL (in blood).
With effective ART, virological suppression can be achieved for most people living with HIV.
People who are virologically suppressed are very unlikely to pass on their HIV infection through
sexual contact [2] and UNAIDS has set the target that 90% of people receiving treatment
should be virologically suppressed.
0% 20% 40% 60% 80% 100%
Men
Women
15-24
25-34
35-49
50+
White
Black African
Other
Gay/bisexual men
Heterosexual men
Heterosexual women
PWID
London
Outside London
Total
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Exp
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HIV in the UK: 2016 report
32
In 2015, 94% (67,628/71,812) of people receiving treatment in the UK with a reported viral load
had an undetectable viral load. Applying this proportion results in 89% of all people living with
diagnosed HIV and 78% of all (diagnosed and undiagnosed) people living with HIV in the UK
with a suppressed viral load17.
17
Viral load information was missing for 14% (12,119) of patients receiving treatment. If the unlikely scenario is assumed that
all missing values related to people with unsuppressed viraemia, the proportion of the diagnosed population who are virally
suppressed reduces to 76%.
HIV in the UK: 2016 report
33
Experiences of people living with HIV
“When I was diagnosed HIV positive it was a very important moment in my life but being HIV positive is not something that defines me necessarily so is actually a very small part of me.” White bisexual man, aged 32
The outlook for people living with HIV in the UK has changed considerably over the past 20
years, with better treatment, increased survival and improved quality of life. Improvements in
treatment coverage have also eliminated the risk of transmission for the majority. Stronger anti-
discrimination laws and policies protecting human rights should also contribute towards an
improved quality of life for people living with HIV.
In 2014, PHE’s Positive Voices survey collected the first round of nationally representative
patient-reported data on a range of health and social issues from a sample of 788 people living
with HIV recruited from 30 HIV clinics across England and Wales [28]. The majority of people
living with HIV describe their overall health to be good or very good (75%) and their clinical care
as excellent and the vast majority adhered to their HIV treatments (93%). Gathering the
experiences of people living with HIV is an important aspect of monitoring the quality of health
care delivered through the NHS.
People with HIV reported exceptionally high levels of satisfaction with their HIV specialist
services, with an average rating of 96 out of 100 (IQR 90-100). Satisfaction with HIV services
was particularly high with regards to having enough information about HIV, feeling supported to
self-manage HIV and being involved in decisions about care. In the previous year, 35% of
people with HIV had accessed HIV support outside the HIV clinic, most commonly for
information about living with HIV, treatment advice, peer support or social contact with other
people living with HIV.
However, despite good self-reported health, about 60% of the participants were classified as
overweight or obese. Co-morbidities were common and almost half of participants reported
taking at least one type of medication in addition to their HIV treatment.
Social inequity was also documented, with high rates of unemployment and poverty. Despite
higher educational attainment than the general population, the employment rate among those
with HIV aged 16-64 was 64% compared with 73% in the UK population during the same period
[29] (Figure 19). People living with HIV reported more financial difficulty, with 15% having fallen
behind with some bills, compared with 6% of the UK population.
HIV in the UK: 2016 report
34
Figure 19: Employment and unemployment rate among people in HIV care compared with the general population[29], ages 16-64: UK, 2014
People also continue to report experiences of stigma and discrimination related to their HIV
status. The People Living with HIV Stigma Survey UK 2015 was a collaborative community-led
initiative in partnership with PHE that captured the experiences of living with HIV in 2015.
A total of 1,576 people, recruited from 120 community organisations and 47 HIV clinics
throughout the UK, completed an anonymous online survey [30]. Two-thirds of participants felt
positive about their life and in control of their health. However, levels of self-stigma were high
with around half reporting shame, guilt or self-blame in relation to their HIV status and one in
five reporting that they had felt suicidal. Furthermore, a high proportion of participants worried
about being gossiped about (27%), had avoided family or social gatherings (11%) and had
experienced sexual rejection (20%) in the past year. To address stigma and discrimination, the
majority of participants in the survey supported increased education (66%) and awareness
campaigns (55%).
“I am who l am – nothing will change that, just proud that l managed to accept my
condition. Let's stand up and support each other, never give a chance to be outcast.”
Black African woman, aged 46
“We are proud to be delivering such outstanding levels of care to those who are accessing it. More than nine out of 10 (96%) of those attending HIV clinics are on treatment and of these 94% have well-controlled HIV and are not infectious to others. However, the fact that 39% of newly diagnosed patients are being diagnosed late remains deeply troubling. This phenomenon is most significant among heterosexual men and women who are not recognised as being at risk and therefore remain undiagnosed for too long. We must continue to push for all doctors in emergency departments, GP surgeries and general hospital settings to be adequately funded and fully empowered to offer and undertake HIV testing."
Dr Chloe Orkin, chair of the British HIV Association (BHIVA)
63.8%
17.4%
73.0%
6.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Employment rate Unemployment rate
HIV population in care
UK General population
HIV in the UK: 2016 report
35
References
1. Cohen, M.S., et al., Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 2011. 365(6): p. 493-505.
2. Rodger, A.J., et al., Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA, 2016. 316(2): p. 171-81.
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17. Birrell, P.J., et al., HIV incidence in men who have sex with men in England and Wales 2001-10: a nationwide population study. Lancet Infect Dis, 2013. 13(4): p. 313-8.
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21. Deaths by single year of age tables - UK. 2015, Office for National Statistics; Available from: http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathregistrationssummarytablesenglandandwalesdeathsbysingleyearofagetables.
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24. Bennett, D.E., et al., Drug resistance mutations for surveillance of transmitted HIV-1 drug-resistance: 2009 update. PLoS One, 2009. 4(3): p. e4724.
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Appendices
Appendix 1: Estimated number of people living with HIV (both diagnosed and undiagnosed) by exposure category: UK,
2015
Exposure category Number diagnosed
Number undiagnosed Total % Undiagnosed
(credible interval)1 (credible interval)
1 (credible interval)
1 (credible interval)
1
Gay/bisexual men 41,180 5,830 47,040 12%
(40,440, 42,030) (3,199, 9,639) (44,219, 50,860) (7, 19%)
People who inject drugs 2,183 315 2,495 13%
(1,967, 2,315) (156, 568) (2,221, 2,785) (7, 21%)
Heterosexuals 42,240 7,190 49,470 15%
(41,530, 43,110) (5,769, 9,459) (47,750, 51,920) (12, 18%)
Men 16,390 3,149 19,550 16%
(16,110, 16,700) (2,239, 5,010) (18,550, 21,470) (12, 23%)
Black African men 8,256 1,001 9,264 11%
(8,083, 8,442) (682, 1,541) (8,873, 9,838) (8, 16%)
Men excluding black Africans 8,135 2,134 10,280 21%
(7,960, 8,320) (1,332, 3,779) (9,448, 11,940) (14, 32%)
Women 25,860 4,000 29,870 13%
(25,330, 26,480) (3,280, 4,900) (28,900, 31,020) (11, 16%)
Black African women 17,450 1,859 19,310 10%
(17,060, 17,890) (1,430, 2,410) (18,710, 20,040) (8, 12%)
Women excluding black Africans 8,410 2,128 10,550 20%
(8,190, 8,667) (1,567, 2,860) (9,910, 11,330) (16, 25%)
Total2
87,670 13,460 101,200 13%
(86,290, 89,320) (10,229, 17,820) (97,469, 105,700) (10, 17%) 1 Lower bound, upper bound.
2 Numbers may not add to total due to rounding and exclusion of data relating to HIV acquired through mother-to-child transmission and blood related products.
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Appendix 2: Estimated number of people living with HIV (both diagnosed and undiagnosed) by exposure category and
region of residence: London, England and Wales, 2015
London England and Wales (excluding London)
Exposure category
Number undiagnosed
Total %
Undiagnosed Number
undiagnosed Total
% Undiagnosed
(credible interval)
1
(credible interval)1
(credible interval)
1
(credible interval)
1
(credible interval)1
(credible interval)
1
Gay/bisexual men 2,129 20,635 10% 2,470 22,700 11%
(719, 5,400) (19,140, 23,920) (4, 23%) (909, 4,780) (21,100, 25,030) (4, 19%)
People who inject drugs
103 809 13% 161 1,181 14%
(45, 206) (704, 931) (6, 23%) (68, 312) (1,028, 1,356) (6, 23%)
Heterosexuals 2,140 18,000 12% 4,430 28,790 15%
(1,520, 3,090) (17,280, 18,980) (9, 16%) (3,310, 6,260) (27,500, 30,700) (12, 20%)
Men 826 6,811 12% 2,014 11,510 18%
(504, 1,488) (6,439, 7,494) (8, 20%) (1,295, 3,486) (10,740, 13,010) (12, 27%)
Black African men 370 3,689 10% 556 5,202 11%
(213, 666) (3,495, 3,994) (6, 17%) (348, 950) (4,939, 5,617) (7, 17%)
Men excluding black Africans
434 3,102 14% 1,441 6,294 23%
(204, 1,022) (2,840, 3,697) (7, 28%) (797, 2,796) (5,627, 7,654) (14, 37%)
Women 1,292 11,170 12% 2,390 17,250 14%
(928, 1,800) (10,710, 11,740) (9, 15%) (1,859, 3,119) (16,560, 18,120) (11, 17%)
Black African women
731 7,751 9% 1,009 10,900 9%
(486, 1,111) (7,432, 8,172) (6, 14%) (730, 1,422) (10,490, 11,400) (7, 13%)
Women excluding black Africans
545 3,401 16% 1,359 6,334 21%
(312, 917) (3,133, 3,784) (10, 24%) (935, 1,990) (5,864, 7,001) (16, 29%)
Total2
4,420 40,250 11% 7,160 53,960 13%
(2,810, 7,809) (38,470, 43,630) (7, 18%) (5,100, 9,870) (51,670, 56,790) (10, 17%)
1 Lower bound, upper bound.
2 Numbers may not add to total due to rounding and exclusion of data relating to HIV acquired through mother-to-child transmission and blood related products.
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Appendix 3: Comparison of estimates for number of people living with HIV (both diagnosed and undiagnosed) using
previously published and revised methods: UK, 2014
2014 estimates (2016 method) 2014 estimates (2015 method)
Exposure category
Number undiagnosed
Total %
Undiagnosed Number
undiagnosed Total
% Undiagnosed
(credible interval)
1
(credible interval)1
(credible interval)
1
(credible interval)
1
(credible interval)1
(credible interval)
1
Gay/bisexual men 5,879 44,480 13% 6,490 44,980 14%
(3,129, 10,249) (41,620, 48,950) (8, 21%) (3,529, 10,899) (41,930, 49,460) (8, 22%)
People who inject drugs
229 2,152 11% 243 2,162 11%
(127, 412) (1,916, 2,380) (6, 18%) (135, 440) (1,918, 2,405) (7, 19%)
Heterosexuals 6,989 48,620 14% 11,160 54,050 21%
(5,750, 8,609) (47,040, 50,460) (12, 17%) (6,240, 18,920) (49,010, 61,920) (13, 31%)
Men 2,940 18,470 16% 5,100 21,290 24%
(2,080, 4,260) (17,510, 19,800) (12, 22%) (2,750, 8,839) (18,910, 25,050) (15, 35%)
Black African ethnicity
1,262 9,207 14% 1,530 9,845 16%
(830, 1,884) (8,706, 9,841) (9, 19%) (291, 3,884) (8,586, 12,220) (3, 32%)
Men excluding black Africans
1,649 9,238 18% 3,570 11,445 31%
(1,051, 2,707) (8,591, 10,290) (12, 26%) (1,815, 6,982) (9,671, 14,880) (19, 47%)
Women 4,020 30,110 13% 6,000 32,680 18%
(3,420, 4,720) (29,200, 31,140) (12, 15%) (3,369,10,509) (29,950, 37,350) (11, 28%)
Black African ethnicity
2,300 19,620 12% 2,380 20,120 12%
(1,879, 2,830) (18,980, 20,340) (10, 14%) (479, 6,090) (18,130, 23,900) (3, 26%)
Women excluding black Africans
1,705 10,490 16% 3,620 12,560 29%
(1,334, 2,195) (10,010, 11,070) (13, 20%) (1,851, 5,535) (10,790, 14,540) (17, 38%)
Total2
13,149 97,610 13% 18,090 103,700 17%
(10,000, 17980) (94,069, 102,700) (11, 18%) (12,100, 26,880) (97,500, 112,700) (12, 24%) 1 Lower bound, upper bound.
2 Numbers may not add to total due to rounding and exclusion of data relating to HIV acquired through mother-to-child transmission and blood related products.
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Appendix 4: Number and proportion of likely recently acquired infections at diagnosis (ascertained through the Recent
Infection Testing Algorithm) by exposure category and age group: England, Wales and Northern Ireland, 20151,2
Exposure category 15-24 25-34 35-49 50-64 Total
Gay/bisexual men
Recent infections 79 198 125 27 429
Number RITA tested 246 677 508 158 1,589
% 32% 29% 25% 17% 27%
95% C.I. (26-38) (26-33) (21-29) (12-24) (25-29)
Heterosexual men
Recent infections 3 15 12 10 40
Number RITA tested 18 94 174 118 404
% 17% 16% 7% 8% 10%
95% C.I. (4-41) (9-25) (4-12) (4-15) (7-13)
Heterosexual women
Recent infections 6 16 13 5 40
Number RITA tested 46 150 231 89 516
% 13% 11% 6% 6% 8%
95% C.I. (5-26) (6-17) (3-9) (2-13) (6-10)
All heterosexuals
Recent infections 9 31 25 15 80
Number RITA tested 64 244 405 207 920
% 14% 13% 6% 7% 9%
95% C.I. (7-25) (9-18) (4-9) (4-11) (7-11)
Total
Recent infections 98 240 159 46 543
Number RITA tested 355 1,008 1,035 425 2,823
% 28% 24% 15% 11% 19%
95% C.I. (23-33) (21-27) (13-18) (8-14) (18-21) 1 Ascertained through the Recent Infection Testing Algorithm (RITA).
2 Overall, nearly 50% of new HIV diagnoses had a test for recent infection; this was similar across all exposure categories.
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Appendix 5: Rates of late diagnosis (CD4 count <350 cells/mm3) by exposure group, ethnicity and gender: England,
2013-2015
Exposure Group
Ethnicity Gender Measure London Midlands and East
of England
North of England
South of England
England total
Gay/bisexual men
Number of diagnoses with CD4 count 4,025 1,101 1,325 1,152 7,603
Number with CD4 count <350 929 410 509 383 2,231
% diagnosed late 23% 37% 38% 33% 29%
Heterosexual contact
Black African
Male
Number of diagnoses with CD4 count 405 239 155 115 914
Number with CD4 count <350 233 165 113 74 585
% diagnosed late 58% 69% 73% 64% 64%
Female
Number of diagnoses with CD4 count 719 415 259 190 1,583
Number with CD4 count <350 384 219 146 111 860
% diagnosed late 53% 53% 56% 58% 54%
White
Male
Number of diagnoses with CD4 count 233 233 244 210 920
Number with CD4 count <350 107 134 140 116 497
% diagnosed late 46% 58% 57% 55% 54%
Female
Number of diagnoses with CD4 count 176 211 174 158 719
Number with CD4 count <350 72 98 79 63 312
% diagnosed late 41% 46% 45% 40% 43%
Other
Male
Number of diagnoses with CD4 count 251 104 58 58 471
Number with CD4 count <350 144 63 39 33 279
% diagnosed late 57% 61% 67% 57% 59%
Female
Number of diagnoses with CD4 count 264 140 71 83 558
Number with CD4 count <350 120 76 30 47 273
% diagnosed late 45% 54% 42% 57% 49%
People who inject drugs
Number of diagnoses with CD4 count 102 73 38 69 282
Number with CD4 count <350 54 38 23 32 147
% diagnosed late 53% 52% 61% 46% 52%
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Appendix 6: Local Authorities (LAs) with diagnosed HIV prevalence rates above 2 per
1,000 population1: England, 2015
HIV prevalence category
Local Authority name
Residents accessing HIV
related care (aged 15-59)
Estimated resident
population in 1,000s
2
(aged 15-59)
Diagnosed HIV prevalence per 1,000 (aged 15-
59)
5+
Lambeth 3,429 234.82 14.60
City of London 77 5.95 12.95
Southwark 2,795 219.98 12.71
Kensington and Chelsea 935 103.11 9.07
Westminster 1,488 167.32 8.89
Hammersmith and Fulham 1,041 124.54 8.36
Lewisham 1,662 201.12 8.26
Islington 1,370 166.01 8.25
Camden 1,339 164.10 8.16
Hackney 1,532 188.89 8.11
Brighton and Hove 1,544 192.51 8.02
Haringey 1,306 186.15 7.02
Newham 1,523 227.53 6.69
Tower Hamlets 1,388 213.39 6.5
Greenwich 1,148 178.94 6.42
Barking and Dagenham 759 123.07 6.17
Manchester 2,101 361.83 5.81
Wandsworth 1,238 221.25 5.6
Croydon 1,251 233.41 5.36
Waltham Forest 886 176.67 5.02
2 - 4.99
Salford 757 152.94 4.95
Brent 904 209.71 4.31
Luton 569 132.27 4.30
Merton 552 131.11 4.21
Enfield 837 202.04 4.14
Hounslow 667 173.04 3.85
Leicester 832 217.72 3.82
Blackpool 303 79.5 3.81
Ealing 756 217.76 3.47
Slough 313 90.75 3.45
Northampton 436 135.32 3.22
Crawley 221 68.68 3.22
Coventry 696 217.35 3.20
Bournemouth 371 120.67 3.07
Reading 318 104.58 3.04
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2 - 4.99
Barnet 700 234.49 2.99
Milton Keynes 472 158.43 2.98
Wolverhampton 446 150.08 2.97
Nottingham 619 213.00 2.91
Redbridge 516 183.96 2.8
Southend-on-Sea 287 102.94 2.79
Watford 168 60.23 2.79
Harlow 141 50.64 2.78
Bexley 385 143.78 2.68
Bromley 513 191.19 2.68
Birmingham 1,818 680.53 2.67
Hillingdon 490 186.31 2.63
Worthing 156 59.89 2.6
Corby 104 40.29 2.58
Sandwell 487 189.17 2.57
Leeds 1,193 480.72 2.48
Richmond upon Thames 291 118.14 2.46
Stevenage 127 52.74 2.41
Bedford 231 97.39 2.37
Harrow 356 150.04 2.37
Sutton 288 121.68 2.37
Wellingborough 98 43.40 2.26
Hastings 119 52.66 2.26
Eastbourne 121 55.33 2.19
Lewes 115 52.89 2.17
Southampton 353 164.19 2.15
Derby 325 151.94 2.14
Bristol, City of 626 292.06 2.14
Kingston upon Thames 236 110.88 2.13
Adur 73 34.35 2.13
Norwich 189 89.93 2.1
Havering 304 145.16 2.09
Trafford 282 136.14 2.07
Rochdale 257 125.62 2.05
Hertsmere 121 59.35 2.04
Thurrock 202 99.63 2.03
Newcastle upon Tyne 385 190 2.03
Oxford 221 109.90 2.01
Rushmoor 120 59.84 2.01 1Complete list of diagnosed HIV prevalence rates available from: www.gov.uk/government/statistics/hiv-annual-data-tables
2 Population data from Office for National Statistics mid-2015 population estimate.
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Appendix 7: List of data sources and associated measures
Data source Description Geographical coverage
Measures
HIV and AIDS Reporting System (HARS)
National HIV surveillance: Linked dataset of people newly diagnosed and seen for HIV care, includes the Recent Infection Testing Algorithm and CD4 surveillance scheme. Data is deduplicated across regions and therefore figures may differ from country-specific data (www.gov.uk/government/collections/hiv-surveillance-data-and-management)
National, England, Wales and Northern Ireland (RITA)
New HIV and AIDS diagnoses, recent infection, late HIV diagnoses, one-year mortality, people seen for HIV care, linkage to HIV care, retention in HIV care, treatment coverage, virological suppression,diagnosed HIV prevalence
Multi-parameter Evidence Synthesis (MPES)
Bayesian multi-parameter evidence synthesis model, reviewed each year to take into account changes in data sources [13]
National, England and Wales, London
Diagnosed and undiagnosed HIV prevalence among the general population and key groups
HIV synthesis progression model
Stochastic simulation model, calibrated to HIV surveillance data [16]
National Undiagnosed HIV prevalence and incidence among the general population
CD4 back-calculation model CD4-based Bayesian back-calculation model [17] England Undiagnosed HIV prevalence and incidence among gay/bisexual men
Probable country of acquisition
CD4 decline model to estimate country of infection for those born abroad [18]
National Probable country of acquisition by exposure group
UK HIV Drug Resistance Database
Molecular surveillance dataset with sequence data for transmitted drug resistance (www.hivrdb.org.uk)
National Transmitted drug resistance by drug class and exposure group
Enhanced Tuberculosis Surveillance System
Data on laboratory isolates and case notifications for TB cases (www.gov.uk/government/collections/tuberculosis-and-other-mycobacterial-diseases-diagnosis-screening-management-and-data)
England, Wales and Northern Ireland
Tuberculosis incidence among people living with HIV
National Study of HIV in Pregnancy and Childhood
Data on pregnant women living with HIV and their children from the Institute of Child Health (www.ucl.ac.uk/nshpc)
National Mother to child transmission of HIV
Positive Voices 2014 PHE-led patient-reported survey data on a range of health and social issues, in collaboration with University College London and Imperial College London (www.ucl.ac.uk/voices)
National Satisfaction with HIV services, health status, adherence to HIV treatment, co-morbidities, social inequity
The People Living with HIV Stigma Survey UK 2015
Survey data on the experiences of living with HIV in 2015, PHE in collaboration with people living with HIV and FPA (www.stigmaindexuk.org)
National Stigma and discrimination related to HIV
Office for National Statistics Population data (www.ons.gov.uk) National UK population, mortality rates
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